Outline Lower Extremity Ultrasound with •Hip MRI Correlation – Effusion – Trochanteric pain syndrome – Iliopsoas snapping Jon A. Jacobson, M.D. • Knee Professor of Radiology – Extensor mechanism Director, Division of Musculoskeletal Radiology • Ankle and Foot University of Michigan – Achilles and peroneal tendons – Gout – Morton neuroma

Hip: anterior recess • Anterior and posterior layers Hip: anterior recess – Fibrous tissue + minute layer of synovium • Anterior +posterior layers – Hyperechoic – Fibrous tissue + Radiology minute layer of Anterior 1999; 210:499 – Each 2 - 4 mm thick synovium Posterior – Hyperechoic Femur – Each 2 - 4 mm thick

Radiology 1999; 210:499

Hip Joint: septic effusion Hip Effusion: misconception • It is incorrect to assume that joint fluid may not be seen anterior due to gravity • Native hip: joint fluid distributes around femoral neck * – In no cases was fluid only seen posterior FH * – Exception: after hip surgery Neck * • US cannot distinguish aseptic from septic * joint Long Axis Moss et al. Radiology 1998; 208:43

1 Joint injection Hip Labrum

• Anterior recess • Normal: Labral Tear • In plane – Hyperechoic, triangular • Degeneration: hypoechoic • Transducer: • Tear: – Parallel to femoral neck – Anechoic cleft – Consider curvilinear – Most common anterior Acetab • Needle: distal to – Possible paralabral cyst Femoral proximal – Sensitivity 82%, Head specificity 60%* • 97% accuracy1 Sagittal-oblique

1 F Smith J. J Ultrasound Med 2009; 28:329 *Jin W et al. J Ultrasound Med 2012; 31:439

Labral Tear and Paralabral Cyst Iliopsoas Bursa: • Hip joint communication in 10% – Increased with hip joint pathology • May extend cephalad into abdomen • May be mistaken for abscess: – Look for hip joint communication

Radiology 1995; 197:853 Courtesy of D. Fessell, Ann Arbor, MI

Iliopsoas Bursal Fluid Total Hip Arthroplasty: • Metal components demonstrate posterior reverberation Acet Femur • Artifact occurs deep to H Neck prosthesis away from IP fluid collection (unlike MRI, CT) Femoral Head Axial T1w post-gadolinium

2 Hip Arthroplasty: infection Hip Arthroplasty:

• Pseudocapsule distention: > 3.2 mm: suspect infection* Superior Inferior • Extra-articular fluid collection: A – Suspect infection > 3.2 mm Head – Not visualized with arthrography if non- Neck communication Native Femur *AJR 1994; 163:381 Sagittal

Metal-on-Metal Arthroplasty: pseudotumor Hip Arthroplasty: infection

Troch Cup Femur Neck Cup

Anterior Lateral Coronal Radiograph

Outline •Hip Trochanteric Pain Syndrome: – Effusion • Most commonly caused by gluteus – Trochanteric pain syndrome minimus and medius tendon 1 – Iliopsoas snapping abnormalities • Knee • Trochanteric bursitis: uncommon 2 – Extensor mechanism – 20% of symptomatic patients 3 • Ankle and Foot – Not actually inflamed 4 – Achilles and peroneal tendons – Not associated with pain 1Eur Rad 2007; 17:1772 – Gout 2Long SS et al. AJR 2013; 201:1083 3Clin Rheumatol 2008; 14:82 – Morton neuroma 4Skeletal Radiol 2008; 37:903

3 Greater Trochanter Greater Trochanter

Yellow arrow = gluteus medius White arrow = Inferior 12 gluteus minimus

Axial MRI 3 Superior 4 Pfirrmann et al. Radiology 2001; 221:469

Greater Trochanter Greater Trochanter Subgluteus Gluteus Medius Medius Gluteus Bursa Minimus TFL Trochanteric Bursa

Glut Subgluteus Max Minimus Bursa LF AF

PF

AF: anterior facet Anterior Posterior LF: lateral facet PF: posterior facet Yellow arrow = gluteus medius White arrow = gluteus minimus

Gluteus Medius: tendinosis

Gluteal Tendon Pathology: • Tendinosis: hypoechoic, no defects • Partial tear: anechoic clefts • Complete tear: discontinuous tendon LF • >2 mm cortical irregularity is associated with Short Axis Long Axis tendon tear – Positive predictive value = 90% (xray)*

*Steinert et al. Radiology 2010; 257:754

4 Calcific Tendinosis: Gluteus Medius Gluteus Medius Fenestration

LF LF Greater AF Trochanter Needle

Normal

Trochanteric Bursitis Outline •Hip – Effusion – Trochanteric pain syndrome – Iliopsoas snapping • Knee PF – Extensor mechanism • Ankle and Foot – Achilles and peroneal tendons Transverse Coronal – Gout – Morton neuroma

Snapping Hip Syndrome: iliopsoas Iliopsoas Complex A 1 2 AIIS

A Ilium B

3

Pubis Red: psoas major Femoral Deslandes et al. AJR Orange: medial iliacus fibers Head Short Axis 2008; 190:576 Purple: lateral iliacus fibers From: Guillin R. et al. Eur Rad 2009; 19:995

5 Snapping Hip Syndrome: iliopsoas Outline • Hip – Effusion – Trochanteric pain syndrome – Iliopsoas snapping • Knee – Extensor mechanism • Ankle and Foot – Achilles and peroneal tendons – Gout – Morton neuroma

Quadriceps Femoris Tear: Quadriceps Tendon: full-thickness tear dynamic imaging

Patella

Longitudinal Sagittal PDw Long Axis

Patellar Tendon: tendinosis Patellar Tendinosis: • Jumper’s knee • Hypoechoic swelling • Mucoid degeneration, possible interstitial tearing • Hyperemia: neovascularity • No inflammatory cells

Radiology 1996; 200:821 color Doppler power Doppler

6 Platelet-Rich Plasma: who cares? Platelet Rich Plasma • Many high-profile athletes claim effectiveness • One of many available systems • Patients are requesting this treatment • Double syringe system • Everyone is doing it • Leukocyte poor • It does work, but maybe not better than • No anticoagulant needed other treatments • Venous draw: 15 ml • Place directly in centrifuge: 5 min • 2 - 5 ml PRP • Platelet concentration: 200 – 500K

PRP: proximal patellar tendon PRP: proximal patellar tendon

Patella

Long Axis Power Doppler

Pre-procedure PRP injection

Short Axis

Patellar Tendon: full-thickness tears Patellar Tendon: full thickness tear

P T Prox Distal

Patient #1

Patient #2 Longitudinal

7 Outline • Hip Achilles Tendon: – Effusion – Trochanteric pain syndrome • 2 – 6 cm proximal to insertion – Iliopsoas snapping – Tendinosis • Knee – Full-thickness tear – Extensor mechanism • Calcaneal attachment • Ankle and Foot – Tendinosis, tear – Achilles and peroneal tendons – Haglund Syndrome – Gout – Morton neuroma

Achilles Tendon: partial-thickness tear Tendinosis: Achilles

Long Axis Longitudinal power Doppler Courtesy of Jon Halperin, San Diego

Achilles Tendon: full-thickness tear Achilles FTT + Intact Plantaris

Plantaris

Transverse Longitudinal Sagittal T2w

8 Achilles Tendon: dynamic imaging Achilles Tendon: healing tear

Prox Distal

Long Axis Longitudinal

Peroneus Brevis Split Peroneus Brevis Split Tear

Short Axis

Peroneal Retinaculum Peroneal Tendon Subluxation:

• Abnormal movement may only occur dynamically • Predisposes to peroneal tendon tears – Longitudinal split of peroneus brevis • US: examine with dorsiflexion / eversion – 100% accurate diagnosis with US

Neustadter et al. AJR 2004; 183:985 Rosenberg et al. AJR 2003; 181:1551

9 Dislocation: peroneus brevis & longus Intrasheath Subluxation

• Abnormal snapping of peroneal tendons Anterior Posterior • No lateral displacement, intact retinaculum • Associations: – Convex posterior fibula in 92% – Tendon tear in 86% – Low lying peroneus brevis muscle in 71%

J Bone Joint Surg Am 2008; 90:992 J Foot Ankle Surg 2009; 48:323 Short axis

Intrasheath Subluxation Outline • Hip – Effusion – Trochanteric pain syndrome – Iliopsoas snapping • Knee – Extensor mechanism • Ankle and Foot – Achilles and peroneal tendons – Gout Transverse – Morton neuroma

Gout: Gout: • Monosodium urate crystals: • Joint effusion / synovial hypertrophy • Double contour sign: – Negative birefringence – Monosodium urate crystal icing on cartilage • Stages: • Tophi: – Asymptomatic hyperuricemia – Hyperechoic with hypoechoic rim – Acute gouty arthritis • Erosions: – Interval asymptomatic phase – Adjacent to tophi – Chronic tophaceous gout – Medial 1st metatarsal head

10 Gout: Double Contour Sign Gout: Double Contour Sign

Normal

Tibia

Metatarsal Head Gout Proximal Talus Phalanx

1st MTP Joint Ankle Joint CPPD

From: Thiele RG, Rheumatology 2007; 46:1116

Gout: tophus Gout: tophus and intra-articular microtophi

PP

MT

PP MT

T1w T2w Gad

st 1st Metatarsophalangeal Joint 1 Metatarsophalangeal Joint

Gout: tibialis posterior tendon Gout: patellar tendon

P

T

11 Gout: popliteus Outline • Hip – Effusion – Trochanteric pain syndrome Tibia – Iliopsoas snapping Femur T2w • Knee – Extensor mechanism • Ankle and Foot – Achilles and peroneal tendons – Gout T2w – Morton neuroma

Morton Neuroma Morton Neuroma:

• Hypoechoic 5 mm mass – Sensitivity: 100% ; Specificity: 83% • Digital nerve continuity* MT – Excludes other causes for mass MT • Compression: – Produces symptoms – Bursa (compressible) vs. neuroma (not compressible) Redd et al. Radiology 1989; 171:415 Transverse Coronal T1w Quinn et al. AJR 2000; 174:1723

Morton Neuroma Dynamic Evaluation • Compression Plantar Dorsal – Between transducer and palpation – Bursae (dorsal) compress, neuromas (plantar) do not • Sonographic Mulder Sign – Scan plantar: coronal plane – Neuroma displaces: plantar Dorsal Plantar – Palpable click

Courtesy of Mark Torriani M et al. AJR 2003; 180:1121 Murphey, MD Zanetti M et al. Radiology 1997; 203:516

12 Dynamic imaging: Mulder’s Maneuver Take Home Points • Hip joint: screen for fluid anterior • Trochanter pain syndrome: not bursitis! • Iliopsoas snapping: dynamic evaluation • Extensor mechanism (knee): not tendinitis • Achilles and peroneals: dynamic imaging • Gout: specific findings • Morton neuroma: dynamic imaging

See www.jacobsonmskus.com for syllabus and other MSK US educational material Twitter handle: @jjacobsn

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